| Organization Name: | TRI STATE FAMILY MEDICAL CENTER, LLC |
| NPI Number: | 1194959452 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | JANICE GAUZE (VICE PRESIDENT) |
| Mailing Address: | 2583 Highway 644 Ste 1 Louisa |
| State: | KY US |
| Postal Code: | 412309436 |
| Phone Number: | 6066383131 |
| Fax Number: | 6066383139 |
| NPI Enumeration Date: | 05/14/2009 |
| NPI Last Update Date: | 12/09/2014 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 363LF0000X |
| License Number: | 3007167 |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | KY |
| Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
| Taxonomy Classification: | Nurse Practitioner |
| Taxonomy Specialization: | Family |
| Taxonomy Definition: | |